Angiogenic Factors in Superimposed Preeclampsia

A Longitudinal Study of Women With Chronic Hypertension

During Pregnancy
Uma Perni, Cristina Sison, Vijay Sharma, Geri Helseth, Amret Hawfield,
Manikkam Suthanthiran, Phyllis August
See Editorial Commentary, pp 555557
AbstractImbalances in circulating angiogenic factors contribute to the pathogenesis of preeclampsia. To characterize
levels of angiogenic factors in pregnant women with chronic hypertension, we prospectively followed 109 women and
measured soluble fms-like tyrosine kinase 1 (sFlt1), soluble endoglin, and placental growth factor at 12, 20, 28, and 36
weeks gestation and postpartum. Superimposed preeclampsia developed in 37 (34%) and was early onset (34 weeks)
in 9 and later onset (34 weeks) in 28. Circulating levels of sFlt1 and the ratio of sFlt1 to placental growth factor were
higher before clinical diagnosis at 20 weeks gestation in women who subsequently developed early onset preeclampsia
between 28 and 34 weeks compared with levels in women who never developed preeclampsia (P0.001) or who
developed late-onset preeclampsia (P0.001). Circulating levels of sFlt1, soluble endoglin, and the ratio of
sFlt1:placental growth factor were also significantly higher, and placental growth factor levels were significantly lower
at the time of clinical diagnosis of superimposed preeclampsia in women with either early or late-onset superimposed
preeclampsia compared with levels at similar gestational ages in those with uncomplicated chronic hypertension.
We conclude that alterations in angiogenic factors are detectable before and at the time of clinical diagnosis of
early onset superimposed preeclampsia, whereas alterations were observed only at the time of diagnosis in women
with late-onset superimposed preeclampsia. Longitudinal measurements of angiogenic factors may help anticipate
early onset superimposed preeclampsia and facilitate diagnosis of superimposed preeclampsia in women with
chronic hypertension. (Hypertension. 2012;59:740-746.)
Key Words: superimposed preeclampsia angiogenic factors chronic hypertension in pregnancy

reeclampsia (PE), a syndrome that manifests in the latter

half of pregnancy and is characterized by maternal
hypertension and proteinuria, develops in 3% to 5% of
pregnant women.1 PE may also develop in women with
chronic (preexisting) hypertension and occurs 3 to 5 times
more frequently compared with women who are normotensive at conception.2 4 The diagnosis of superimposed PE
(SPE) is often difficult, because women already have hypertension and some even have proteinuria. SPE is associated
with even greater maternal and fetal morbidity and mortality
than PE in women without preexisting hypertension.2,5
The pathogenesis of PE, as well as SPE, is likely to involve
placental vascular remodeling, leading to defective placentation,6,7 placental ischemia,8,9 and maternal endothelial cell
dysfunction.10 Emerging data suggest that placental ischemia
is associated with increased production of placental proteins,

which, on release into the maternal circulation, cause maternal systemic inflammation and endothelial cell dysfunction.11,12 In particular, an imbalance in circulating proangiogenic and antiangiogenic factors released by the hypoxic
placenta has gained currency as a critical link between
placental dysfunction and several maternal manifestations of
PE, particularly endothelial dysfunction and proteinuria.13
Results from clinical trials suggest that the soluble forms of
the vascular endothelial growth factor receptor 1, soluble fms
like tyrosine kinase-1 (sFlt1) and soluble endoglin (sEng),
both classified as antiangiogenic factors, are elevated in
maternal blood of women before and at the time of diagnosis
of PE, whereas the levels of the proangiogenic factor placental growth factor (PlGF) are reduced.14 16 Alterations in the
levels of circulating factors in women with chronic hypertension are beginning to be appreciated primarily after crosssectional analyses of subgroups.1719

Received September 2, 2011; first decision September 25, 2011; revision accepted January 5, 2012.
From the Division of Maternal-Fetal Medicine (U.P.), Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Feinstein
Institute for Medical Research (C.S.), North Shore-Long Island Jewish Health System, Manhasset, NY; Wake Forest School of Medicine (A.H.),
Winston-Salem, NC; Weill-Cornell Medical School (V.S., G.H., M.S., P.A.), New York, NY.
Correspondence to Phyllis August, Hypertension Center, Weill Cornell Medical College, 450 East 69th St, New York, NY 10021. E-mail
paugust@med.cornell.edu
2012 American Heart Association, Inc.
Hypertension is available at http://hyper.ahajournals.org

DOI: 10.1161/HYPERTENSIONAHA.111.181735

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by guest on January 6, 2016
740

Perni et al
The current investigation was designed to characterize the
levels of circulating sFlt1, sEng, and PlGF in women with
preexisting hypertension and to investigate whether longitudinal profiling can help distinguish chronically hypertensive
pregnant women who develop SPE from those who do not
develop SPE. In this study, we have leveraged and performed
a secondary analysis of the peripheral blood specimens
originally collected longitudinally in the context of a placebocontrolled, double-blinded randomized trial of calcium supplementation in chronically hypertensive pregnant women
and demonstrate significant alterations in sFlt1, sEng, and
PlGF before the clinical diagnosis of early onset (34 weeks)
SPE and at the time of diagnosis in women with both early
and late-onset SPE. Our findings supporting the hypothesis
that measurement of angiogenic factors may be helpful in the
diagnosis of SPE in women with chronic hypertension form
the basis of this report.

Methods
Subjects
Clinical data and venous peripheral blood were collected as part of
the Chronic Hypertension in Pregnancy Study, a placebo-controlled,
double-blinded randomized trial of calcium for the prevention of PE
in women with preexisting chronic hypertension performed at New
York Presbyterian-Weill Cornell, which concluded in 1999.20 The
study protocol was approved by the institutional review board at
Weill-Cornell Medical College, and informed consent was obtained
at the initial visit. Eligible women were 18 to 45 years of age who
were 12 to 15 weeks pregnant and had blood pressure 140/
90 mm Hg either before pregnancy or in the first trimester or who
were on active treatment for chronic hypertension. Women with a
serum creatinine 1.2 mg/dL or creatinine clearance 75 mL/min
were excluded from the Chronic Hypertension in Pregnancy Study.
Data analysis was carried out on a cohort of 109 women whose
pregnancies progressed beyond 20 weeks.

Study Protocol
Pregnant women with chronic hypertension were randomly assigned
to treatment with either calcium carbonate (2000 mg daily) or
placebo. Blood pressure, weight, and brief history and physical were
performed at baseline (1215 weeks gestation) and every 4 weeks
until the third trimester and then every 1 to 2 weeks until delivery. At
baseline; 20, 28, and 36 weeks; and 6 weeks post partum, maternal
venous blood was collected in standard serum separator tubes and
stored at 80 until analysis for angiogenic factors 8 years later.
Previous studies have documented the stability of angiogenic factors
in specimens stored for 12 years.16 Additional institutional review
board approval was obtained to analyze stored specimens for
angiogenic factors. Soluble Flt1, sEng, and PlGF were measured
using solid-phase, quantitative sandwich ELISA using ELISA kits
(R&D Systems Inc, Minneapolis, MN) and following the manufacturers instructions. All of the samples were run in duplicate by a
single investigator (U.P.), who was blinded to clinical outcomes. A
standard curve was constructed using recombinant human sFlt1,
sEng, or PlGF, and a curve-fitting software program was used to
quantify the concentration of sFlt1, human sEng, or recombinant
PlGF. According to the kit manufacturer, the mean minimum
detectable dose of sFlt1 is 3.5 pg/mL, and the intra-assay and
interassay median coefficients of variation (CVs) were 3.2% and
7.0%, respectively, and in our laboratory the intra-assay and interassay CVs were 2.4% and 10.7%, respectively. The mean minimum
detectable dose of sEng is reported as 7.0 pg/mL, and the intra-assay
and interassay CVs were 3.0% and 6.5%, respectively; in our
laboratory the intra-assay and interassay median CVs were 1.9% and
12.7%, respectively. The mean minimum detectable dose of PlGF is
reported as 7.0 pg/mL; the intra-assay and interassay CVs were 5.6%

Angiogenic Factors in Superimposed Preeclampsia

741

and 11.0%, respectively; and in our laboratory the intra-assay and

interassay CVs were 1.6% and 9.7%, respectively.
Pregnancy outcomes were ascertained by detailed chart review of
each case shortly after delivery by the principal investigator of the
clinical trial, and each patient was given either a diagnosis of SPE or
no SPE. We diagnosed SPE if there was a significant increase in
blood pressure compared with baseline (30 mm Hg systolic,
15 mm Hg diastolic) in association with new-onset proteinuria
(either 300 mg per 24 hours or 2 by dipstick on 2 occasions).
If proteinuria was present at baseline, SPE was diagnosed if there
was doubling of urinary protein excretion after 20 weeks gestation
in association with a significant increase in BP. SPE was also
diagnosed if blood pressure was elevated and there were elevated
liver enzymes (2 times baseline) and a low platelet count
(100 000). Cases of SPE were classified as early onset (34
weeks gestation) or late onset (34 weeks gestation).

Statistical Analysis
All of the statistical analyses were performed using SAS version 9.2
(SAS Institute, Cary, NC). Continuous variables were summarized
using mean and SD, and comparisons between groups were made
using Student t test or Mann-Whitney test as appropriate for 2-group
comparisons and either ANOVA or Kruskal-Wallis test as appropriate for multiple group comparisons. Post hoc testing using a
Bonferroni-type adjustment (P0.01) was used to compare early and
late SPE with women with no PE. Categorical variables were
summarized using proportions, and comparisons between groups
were made using either the 2 test or Fisher exact test, as appropriate.
Multivariable modeling using logistic regression along with a backward elimination algorithm was performed to determine whether
levels of sFlt1, sEng, or sFLt1/PlGF were independent predictors of
developing either early onset or late-onset SPE. All of the P values
are 2 tailed, and a P value of 0.05 was considered significant.

Results
We enrolled 110 pregnant women with chronic hypertension
in our clinical trial. Stored aliquots of sera were available
from all but 1 study participant. The meanSD age of the 109
subjects was 335.6 years, most were overweight or obese,
and 40% were black. Forty-one percent were nulliparous,
and of the 64 multiparous women, 30% had a history of
previous PE. Thirty seven (34%) of the 109 women developed SPE, 9 (8%) of 37 developed early onset (34 weeks)
SPE, and the remaining 28 (25%) developed later onset SPE
(after 34 weeks; Table 1). Women who developed early onset
SPE were more likely to have secondary hypertension compared with women with later onset SPE or no SPE; 1 had type
1 diabetes mellitus, 1 had lupus with previous nephritis, and
1 had a well-functioning renal allograft. As expected, women
with both early onset and late-onset SPE were more likely to
have had PE in a previous pregnancy compared with women
with no SPE (P0.04). There were no statistically significant
differences in age, race, parity, body mass index, blood
pressure, or renal function assessed at 12 weeks gestation in
women who developed early onset, late-onset, or no SPE
(Table 1). Women with early onset SPE delivered earlier and
had smaller and more growth-restricted infants compared
with women with either late or no SPE (P0.0001; Table 2).

Circulating Levels of Angiogenic Factors in

Sequential Serum Samples
Circulating levels of both antiangiogenic (sFlt1 and sEng)
and proangiogenic (PlGF) factors were increased during
pregnancy in all of the women compared with postpartum

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742

Hypertension
Table 1.

March 2012

Baseline Clinical Characteristics

Variable

Early PE (N9)

Late PE (N28)

No PE (N72)

P*

Age, y

32.34.0

32.95.8

33.25.7

0.97

Race, black (%)

5/9 (56)

9/28 (32)

29/72 (40)

0.43

Secondary hypertension (%)

4/9 (44)

2/28 (7)

4/72 (6)

0.005

Previous PE (%)

3/6 (50)

9/19 (47)

8/40 (20)

0.046

Primiparous (%)

4/9 (44)

9/28 (32)

33/72 (44)

0.55

BMI, kg/m

28.57.7

35.09.2

30.597.8

0.06

SBP, mm Hg

12813

13112

12712

0.37

DBP, mm Hg

8310

8110

8110

0.81

0.790.25

0.700.14

0.670.19

0.27

Creatinine, mg/dL
Creatinine clearance, mL/min

12762

14946

15751

0.28

Plasma renin activity, ng/mL per h

5.872.69

6.022.99

6.173.01

0.90

PE indicates preeclampsia; BMI, body mass index; SBP, systolic blood pressure; DBP, diastolic blood pressure; early PE,
superimposed preeclampsia diagnosed before 34 wk gestation; late PE, superimposed preeclampsia diagnosed at or after 34 wk
gestation; no PE, no superimposed preeclampsia; secondary HTN, hypertension associated with kidney disease, lupus, or primary
aldosteronism. Continuous variables are shown as meanSD.
*P value was calculated using the Kruskal-Wallis test, and P0.05 considered significant.

levels (Table 3 and Figures 1 and 2). Calcium therapy had no

influence on any of the angiogenic factor levels at any time
during pregnancy (data not shown). Baseline levels (obtained
between 12 and 14 weeks gestation) of all of the factors were
similar among women with early, late, or no SPE . sFlt1
levels were significantly higher at 20 and 28 weeks in women
with early onset SPE compared with women with later onset
or no SPE. sFlt1 was significantly higher in women with
late-onset compared with no SPE only at 36 weeks (Figure
1A and Table 3). sEng levels were higher at 28 weeks in
women with early onset SPE compared with those with late
or no SPE and were higher at 36 weeks in women with
late-onset SPE compared with women without SPE (Figure
1B and Table 3). In contrast to the circulating levels of
antiangiogenic sFlt1 or sEng, the levels of proangiogenic
PlGF were significantly lower at 28 weeks in women with
early onset SPE compared with those without SPE and were
also lower at 28 and 36 weeks in women with late-onset SPE
compared with no SPE (Figure 2A and Table 3). Angiogenic
factor levels measured 6 to 10 weeks postpartum were similar
in all of the groups.
Table 2.

Pregnancy Outcomes by Final Diagnosis

Variable

Early PE (N9)

Late PE (N28)

No PE (N73)

Gestational age, wk

28.74.97*

36.43.3

37.53.9

Birth weight, g

1341715*

2759.2638

3031.4739

SGA (%)

3/8 (38)

3/27 (11)

0/71 (0)

Cesarian section (%)

7/8 (88)

17/27 (63)

30/71 (42)

PE indicates preeclampsia; early PE, superimposed preeclampsia diagnosed

before 34 wk gestation; late PE, superimposed preeclampsia diagnosed at or
after 34 wk gestation; no PE, no superimposed preeclampsia; gestational age,
gestational age at delivery; SGA, small for gestational age. Continuous variables
are shown as meanSD.
*P0.0001 vs late PE and no PE.
P0.002 vs no PE.
P0.017 vs no PE.
P0.001 vs no PE.
P0.02 vs no PE.
P0.02 vs no PE.

We calculated the ratio of sFlt1:PlGF because it captures

the reciprocal changes between sFlt1 and PlGF and has been
shown to be strongly associated with PE.15 Values of this
ratio were significantly higher at 20 and 28 weeks in women
with early onset SPE compared with the late-onset or no SPE
groups (Figure 2B and Table 3); the sFlt1/PlGF ratio was also
significantly higher at 36 weeks in women with late-onset
SPE compared with those with no SPE.

Prediction of SPE
There has been considerable interest in determining whether
alterations in angiogenic factors can identify women at
increased risk for PE. We reported previously that 3 easily
ascertained clinical and laboratory variables (systolic BP,
serum uric acid, and plasma renin activity) measured at 20
weeks predict SPE in women with chronic hypertension.20
We reassessed the ability to predict SPE in this population
using our previous prediction model cut points (serum uric
acid: 3.6 mg/dL; plasma renin activity: 4 ng/mL per hour;
systolic blood pressure: 140 mm Hg) and analysis involving receiver operating characteristic curve showed that the
area under the curve was 0.764. Inclusion of angiogenic
factor levels in this prediction model and application of a
backward elimination algorithm showed that only sFlt1/PlGF
improved the predictive accuracy of the model, with the area
under the curve increasing from 0.764 to 0.852.

Discussion
We conducted a longitudinal study of pregnant women with
chronic hypertension and report that circulating levels of the
antiangiogenic factor sFlt1 and the ratio of sFlt1/PlGF were
higher at midpregnancy (20 weeks) in women who were
subsequently diagnosed with early onset (34 weeks gestation) SPE compared with women who did not develop SPE
and also compared with those who were diagnosed with
late-onset SPE (34 weeks gestation). sFlt1 levels were also
higher at 28 weeks in women with early onset SPE and at 36

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Perni et al
Table 3.

Angiogenic Factors in Superimposed Preeclampsia

743

Levels of Angiogenic Factors During Pregnancy by Diagnosis Group and Gestational Age

Variable

Early PE (N9)

Late PE (N28)

No PE (N73)

P*

Early PE
vs Late PE

Early PE
vs No PE

Late PE
vs No PE

12 wk (baseline)

n9

n23

n65

sFlt1, pg/mL

2205.31169

1471.8881.4

1834.51039.8

0.054

7.72.0

6.72.7

7.23.3

0.216

Endoglin, ng/mL
PlGF, pg/mL

100.873.6

74.161.3

77.056.5

0.796

sFlt1/PlGF

35.826.5

27.218.9

38.453.7

0.445

PlGF/endoglin

14.413.6

11.57.5

14.621.9

0.996

n8

n24

n64

5813.64899

20 wk

1426.61132.2

2076.02452.1

0.0001

0.001

0.001

0.006

25.237.5

6.64.3

6.32.8

0.057

0.039

0.036

0.307

PlGF, pg/mL

136.3109.5

228.8150.2

272.6169.8

0.045

0.112

0.021

0.236

sFlt1/PlGF

131.8192.4

7.45.3

10.316.5

0.001

0.0007

0.001

0.240

26.028.5

39.321.8

45.425.1

0.101

0.122

0.052

0.323

n8

n25

n65

1313911848

2702.13546.2

2176.21998.3

0.002

0.002

0.001

0.466

36.135.7

9.36.9

7.44.0

0.004

0.012

0.001

0.340

PlGF, pg/mL

247.6368.9

422.3272.5

525.2243.4

0.003

0.038

0.006

0.024

sFlt1/PlGF

496.7670.2

9.313.1

5.56.2

0.007

0.011

0.003

0.368

35.563.5

62.247.0

166.8667.3

0.001

0.027

0.003

0.018

n24

n58

sFlt1, pg/mL
Endoglin, ng/mL

PlGF/endoglin
28 wk
sFlt1, pg/mL
Endoglin, ng/mL

PlGF/endoglin
36 wk
sFlt1, pg/mL

NC

83416979

44232995

0.014

0.014

Endoglin, ng/mL

NC

21.9017.11

12.997.79

0.016

0.016

PlGF, pg/mL

NC

258.9142.9

424.1208.5

0.0003

0.0003

sFlt1/PlGF

NC

52.179.20

13.9613.28

0.0001

0.0001

0.0001

PlGF/endoglin

NC

19.6518.37

74.28238.0

n8

n21

n53

223.045.96

180.052.94

216.9189.3

0.057

6.351.65

5.711.95

5.501.33

0.395

PlGF, pg/mL

11.153.56

11.122.70

10.262.15

0.553

sFlt1/PlGF

21.196.05

17.176.80

21.8419.76

0.122

1.810.51

2.150.89

1.930.50

0.556

Postpartum
sFlt1, pg/mL
Endoglin, ng/mL

PlGF/endoglin

Levels of angiogenic factors are expressed as meanSD. PE indicates preeclampsia; sFlt1, soluble fms-like tyrosine kinase 1; PlGF, placental growth factor; early
PE, superimposed preeclampsia diagnosed before 34 wk gestation; late PE, superimposed preeclampsia diagnosed at or after 34 wk gestation; no PE, no
superimposed preeclampsia.
*P value was calculated using Kruskal-Wallis test, P0.05 considered significant.
P value was calculated using Mann-Whitney test, P0.01 considered significant.
P0.05.
NC indicates that specimens were not collected because patients with early PE had already delivered by 36 wk.
Postpartum specimens were collected 6 wk after delivery.

weeks in those with late-onset SPE compared with levels at

similar gestational ages in those without SPE.
Endoglin is a homodimeric receptor for transforming
growth factor- family members and plays an important role
in angiogenesis, hematopoiesis, and cardiovascular development; PlGF is an angiogenic factor that belongs to the
vascular endothelial growth factor family. Circulating levels
of sEng were higher and PlGF lower when SPE was already
diagnosed by clinical criteria in women with early onset and
late-onset SPE compared with women without SPE. The ratio
of sFlt1/PlGF was higher at the time of clinical diagnosis in
both early onset and late-onset SPE, compared with women
who never developed SPE. The ratio of PlGF/endoglin was

lower at the time of clinical diagnosis in early and late PE

compared with women who did not develop SPE.
These alterations in angiogenic factors in women who
developed SPE mimic those reported in women who develop
PE who were previously normotensive and suggest similarities in the pathogenesis of PE and SPE.14 16,21 Although the
alterations in angiogenic factors were more striking in women
with early onset compared with late-onset SPE, angiogenic
factor alterations were clearly detectable in those with lateonset SPE close to the time of diagnosis. It has been
suggested that severe placental dysfunction is a distinguishing feature of early onset PE, whereas women who develop
PE close to term are more likely to have maternal predispos-

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744

March 2012

20000

600

15000

500

10000

400

PIGF (pg/ml)

sFLt1 (pg/ml)

Hypertension

5000

300

200

0
12

20

28

36

PP

WEEKS GESTATION
50

100

40

30

20

12

20

28
36
WEEKS GESTATION

PP

12

20

28
36
WEEKS GESTATION

PP

800

600

sFIt1/PIGF

ENDOGLIN (ng/ml)

10

0
12

20

28

36

PP

400

200

WEEKS GESTATION

Figure 1. Circulating levels of soluble fms-like tyrosine kinase

1 (sFlt1) and soluble endoglin (sEng) in women with early
onset superimposed preeclampsia (SPE), late-onset SPE, or
no PE. A and B show meanSD levels of sFlt1 and sEng during pregnancy and 6 weeks postpartum in women with
chronic hypertension with no SPE (light blue broken lines);
those with early onset SPE (solid red lines); and those with
late-onset SPE (broken green lines). Specimens were collected within a window of 2 weeks before or after the time
points on the x axis. Women with early onset SPE did not
contribute any specimens at 36 weeks because they had all
delivered. A, Levels of sFlt1 were higher in women with early
onset SPE at 20 weeks (P0.001) and 28 weeks (P0.002)
gestation compared with the other groups. sFlt1 levels were
lower in women with late-onset SPE at 20 weeks compared
with those with no SPE (P0.006). sFlt1 levels were higher in
women with late-onset SPE at 36 weeks compared with
those with no SPE (P0.014). B, sEng levels were higher in
women with early onset SPE at 20 and 28 weeks gestation
compared with women with late-onset SPE (P0.039 and
0.012, respectively) and also compared with women with no
SPE (P0.036 at 20 weeks; P0.001 at 28 weeks). sEng levels were higher in women with late-onset SPE at 36 weeks
gestation compared with those with no SPE (P0.016).

Figure 2. Levels of placental growth factor (PlGF) and the

ratio of soluble fms-like tyrosine kinase 1 (sFlt1) to PlGF in
women with early onset superimposed preeclampsia (SPE),
late-onset SPE, or no PE. A and B show meanSD levels of
PlGF and the ratio of sFlt1/PlGF during pregnancy and 6
weeks postpartum in women with chronic hypertension with
no SPE (light blue broken lines); those with early onset SPE
(solid red lines); and those with late-onset SPE (broken green
lines). Specimens were collected within a window of 2 weeks
before or after the time points on the x axis. A, Levels of
PlGF were lower in women with early onset SPE at 20 and 28
weeks gestation compared with those with no SPE (P0.021
and P0.006, respectively) and were lower at 28 weeks compared with those with late-onset SPE (P0.038). PlGF levels
were lower in women with late-onset SPE at 36 weeks compared with those with no SPE (P0.0003). B, sFlt1/PlGF ratio
was higher in women with early onset SPE at 20 and 28
weeks gestation compared with those with either late-onset
SPE (P0.0007 and P0.011, respectively) or no SPE
(P0.001 and P0.003). sFlt1/PlGF ratio was higher in
women with late-onset SPE at 36 weeks compared with
those with no SPE (P0.0001).

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Perni et al
ing risk factors, such as hypertension, obesity, and diabetes
mellitus, and less likely to have clinically apparent placental
dysfunction.2226 It has also been suggested that women with
chronic hypertension or diabetes mellitus develop PE in the
context of smaller increments of sFlt and sEng, because there
is already preexisting maternal endothelial cell dysfunction.27
Our finding of more significant alterations in angiogenic
factors in early versus late-onset SPE are consistent with
reports that more severe placental dysfunction distinguishes
early onset from late-onset SPE in women without preexisting hypertension. It should be noted that angiogenic factors
were clearly altered even in late-onset SPE close to the time
of diagnosis, suggesting that placental dysfunction plays a
role in both early onset, as well as late-onset, SPE, albeit to a
different degree. We did not collect data on angiogenic
factors in normotensive pregnant controls, thus we cannot
determine whether the levels in chronic hypertensives who
did not develop PE were similar to normotensive pregnant
women, although results from other published studies suggest
that they are.17,18 The levels that we report in women who
developed SPE are also similar to previous reports in women
who developed SPE and who were sampled only twice during
pregnancy.17 Our study, in which angiogenic factors were
measured every 8 weeks and postpartum in the same patients,
both confirms and adds to these previous reports.
The 9 women with early onset SPE had different baseline
characteristics compared with the other groups. They had
slightly lower body mass index, were more likely to have
secondary causes of hypertension, and some had baseline
proteinuria. Diagnosing PE in women with preexisting hypertension and proteinuria is challenging, thus the elevations
in sFlt1, sEng, and sFlt/PlGF that we observed suggest that
measurement of these factors might be useful for diagnosing
SPE in these women.
There has been considerable interest in identifying biomarkers for the prediction of PE. Although serum levels of
angiogenic factors are clearly different in PE compared with
normotensive pregnancy at the time of diagnosis, as well as
weeks before, whether they have sufficient sensitivity or
specificity to be useful in clinical prediction has not been
resolved. We performed multivariable modeling to determine
predictors of SPE, because we have reported previously that
easily ascertained clinical and laboratory measurements (systolic blood pressure, uric acid, and plasma renin activity)
obtained at 20 weeks may be useful for prediction.20 Although the addition of the ratio of sFlt1/PlGF to the 3-variable model that we reported previously resulted in an increased area under the curve for prediction of early onset PE,
our sample size was not large enough to accurately evaluate
prediction.
Our study has limitations. More than one third of the
women were multigravidas, and some had baseline proteinuria, characteristics known to confound the diagnosis of PE.28
However, the accuracy of the diagnosis of SPE is supported
by the significant differences in relevant clinical outcomes
between women with early SPE and no SPE, as well as
differences between women with late SPE and no SPE.
Women with both early and late SPE delivered earlier, had
smaller infants, had a higher proportion of infants with

Angiogenic Factors in Superimposed Preeclampsia

745

growth restriction, and more cesarean sections compared with

women without SPE (Table 2). Additional studies evaluating
the relationship between angiogenic factors and these adverse
outcomes would be of interest and might strengthen our
finding that angiogenic factor measurements identify women
at risk.
Our aim was to gain insight into the pathogenesis of SPE,
and we believe our results show that early onset SPE
compared with late-onset SPE is associated with more striking alterations in angiogenic factors both before clinically
apparent disease and at the time of diagnosis, similar to
observations in early onset PE in women who were normotensive before pregnancy.18,25,29 Although small sample size
is another limitation of our study, management and follow-up
were standardized, PE was diagnosed in all of the cases by 1
investigator (P.A.), and data collection was complete, with
almost all of the subjects contributing both clinical and
laboratory information at all of the time points. Our findings
provide insight into pathogenesis of SPE, and we suggest that
the utility of measuring angiogenic factors to predict and/or
diagnose SPE requires further validation and is of potential
clinical significance.

Perspectives
Women with chronic hypertension are at increased risk for
developing SPE, a condition with significant maternal and
fetal morbidity and mortality. Altered levels of circulating
angiogenic factors have been reported in women with PE who
were previously normotensive and also in cross-sectional
studies of women with chronic hypertension in pregnancy. In
a longitudinal prospective study of women with chronic
hypertension, we observed similar alterations in angiogenic
factors before and at the time of diagnosis in women with
SPE. Our findings suggest similarities in the pathogenesis of
PE and SPE. Measurement of sFlt1 and the ratio of sFlt1/
PlGF may be useful diagnostic tests in women with chronic
hypertension, particularly those with baseline proteinuria or
secondary hypertension in whom recognizing PE is often
more challenging.

Sources of Funding
This work was supported by National Institutes of Health grant R01
HL 488-46.

Disclosures
None.

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Angiogenic Factors in Superimposed Preeclampsia: A Longitudinal Study of Women With

Chronic Hypertension During Pregnancy
Uma Perni, Cristina Sison, Vijay Sharma, Geri Helseth, Amret Hawfield, Manikkam
Suthanthiran and Phyllis August
Hypertension. 2012;59:740-746; originally published online February 6, 2012;
doi: 10.1161/HYPERTENSIONAHA.111.181735
Hypertension is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright 2012 American Heart Association, Inc. All rights reserved.
Print ISSN: 0194-911X. Online ISSN: 1524-4563

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